Student ed|atr|c Assessment

?our name uaLe of Care $$ L Age mos L Cender I

AdmlLLlng ulagnosls kesp|ratory D|stress
er arenL/Chlld 8eason for Admlsslon Ch||d was hav|ng d|ff|cu|ty breath|ng
rlmary Careglver Mom Llves wlLh Mom and Dad and brothers lamlly Mom Dad and two brothers
Slbllngs (ages llvlng wlLh healLh) Mark y$o and Nadasean 4 y$o both have asthma
rlmary Language Lng||sh eLs None 8ecenL lamlly Crlsls No
Crade ln school n$a uevelopmenLal level mos MllesLones meL? S|ts ro||s over a|most craw||ng
uleL/AppeLlLe Iormu|a and pureed fru|ts LllmlnaLlon N$A
Sleep aLLerns 1hrough n|ght naps 2 3 t|mes a day ually 8ouLlne Lats naps s|eeps p|ays
AcLlvlLy/SafeLy lssues Ch||d |s a|most craw||ng and can stand w|th ass|stance S|de ra||s and safety precaut|ons must be
taken such as not |eav|ng ch||d on car seat on a tab|e or on a bed unattended
revlous lllnesses Ch||d had a s|m||ar |nc|dent 2 mos ago
revlous hosplLal admlsslons (uaLe(s) reason Ch||d was hosp|ta||zed 2 mos Ago w|th the same d|agnos|s
lmmunlzaLlons upLodaLe? LS lf noL why noL?_________________________________________
MedlcaLlons Laken aL home (lnclude C1C) A|butero| INn as needed 1y|eno| as needed
Allergles (1ype 8eacLlon) "Seasona|"
1 92 A 3 k 3 8/ 4$ ulse Cx 9 Aln None PL WL 4 kg 8ecenL changes No
lnLake 8 f| oz CuLpuL (2 wet d|apers)

Assessment I|nd|ngs Inc|ude ob[ect|ve and sub[ect|ve
neurologlcal Ch||d |s act|ve sm|||ng and perform|ng age appropr|ate fac|a| epress|ons gestures and |m|tat|ng
8esplraLory
Ch||d |s wheez|ng v|s|b|e retract|ons w|th a mucous cough Wheez|ng heard w|th and w|thout a
stethoscope

Cardlac

SS2 kegu|ar rate and rhythm ap|ca| pu|se 3 8 4$
Cl

8owe| sounds detected |n a|| four quadrants no bowe| movement observed
Cu
1 had two wet d|apers Ur|ne was ||ght ye||ow no detectab|e odor or abnorma||t|es

MusculoskeleLal
I|rm grasp b||atera| strength Good musc|e tone

Skln/ Wound Sk|n |s smooth ||ght brown no scarr|ng or |es|ons or b|em|shes

sychosoc|a| Ch||d arent$Careg|ver
Level of AnxleLy M||d|y an|ous dur|ng treatment (Neb)
M||d|y an|ous wh||e ta|k|ng to the doctor
Coplng 8ehavlors
Squ|rmed tr|ed to push away

1r|ed to get answers from the Dr as to cause
of ch||d's wheez|ng
Labs at|ent va|ue Norma| range S|gn|f|cance
W8C SS 8
88C
Pgb

PcL
lLs
Clu(l8S) 9
nA 4 3S 4S
k 4 3S S
Cl 99 9
Co
2
2 S 3S
8un S 2
Cr 2 4 Low (|ow creat|n|ne may |nd|cate de creased k|dney funct|on)
Ca
Mg 2
C
4

Clu (s)
h
pCC
2

pC
2

PCC
3

CLher labs/dlagnosLlc LesLlng Chest wray was ordered to ru|e out pneumon|a ray d|d not detect any
abnorma||t|es

A1nCnSICLCG
1he ch||d had an ep|sode of wheez|ng$resp|ratory d|stress a coup|e of months ago 1he ch||d was sent home and
parents were to use the nebu||z|ng treatment as needed 1he ch||d goes to day care and they used |t there once a
day for 2 3 t|mes a week 1he ch||d was eper|enc|ng s|m||ar ep|sodes on Monday and when the parent ca||ed the
MD she was to|d to br|ng the ch||d to the Lk 8|ood tests were ordered a chest ray was done (an IV was tr|ed but
unsuccessfu|) and an |n[ect|on of redn|sone was g|ven 1he ch||d was adm|tted to the hosp|ta| for further mon|tor|ng

lluld MalnLenance Lnfam|| baby formu|a

Cxygen None

8esplraLory Nebu||zer treatments due to wheez|ng Mon|tor oygen saturat|on |eve|s

Wounds None

hyslcal/CccupaLlonal/Speech
CLher 1reaLmenLs/1herapy/1herapeuLlc uevlces None

keferra|s

Meds
Gener|c$8rand dose
Safe?
koute?
Why |s pt rece|v|ng?
Act|on?
Assess before
adm|n?
S|de Lffects$ 1o|c Lffects
Nurs|ng Imp||cat|ons$1each|ng
A|butero|$Accuneb INn
SCL
2Smg$3 m| 4n

Dose Safe
Inha|ed
8rochod||ator to reverse
a|rway obstruct|on caused
by asthma
Lung sounds
pu|se 8
Depress|on d|zz|ness fat|ge
weakness bronchospasm
cough dyspnea anore|a
const|pat|on
Cort|costero|ds
Nasa|$8udeson|de
Smg$2m| INn Susp

Dose
safe$Inha|ed
Loca||y act|ng ant|
|nf|ammatory
kesp|ratory
status |ung
sounds
neadache ag|tat|on
depress|on |nsomn|a
rest|essness

Cort|costero|ds
System|c$redn|soLone
SCD nCS Smg$Sm|
22mg$33m| ora| da||y

Safe ( 2
mg$kg$day)
Cra|
Suppresses |nf|ammat|on
and the auto |mmune
response
Assess
|nvo|ved
systems
IC arean|
suff|c|ency
neadache depress|on
|ntracran|a| pressure
psychoses rest|essness
vom|t|ng acne












Growth Deve|opment Assessment Clve examples of observed behavlors ln each caLegory Any concerns?
Chronologlcal Age mos uevelopmenLal Age mos Lrlcksen uevelopmenLal SLage 1rust vs M|strust

CrossmoLor Craw|s S|ts up u||s to stand ko||s over

llnemoLor Grasps w|th thumb and foref|nger Im|tates c|ap

Language Cr|es Makes g|bber|sh sounds

1wo examples of behavlors lndlcaLlng paLlenL's achlevemenL of developmenLal Lask
) 1he ch||d tr|ed to |m|tate the mothers c|app|ng
2) 1he ch||d opened and c|osed her hand as |f to wave

Were Lhere any medlcal/nurslng lnLervenLlons LhaL lnLerrupLed normal growLh and developmenL?
Noth|ng apparent

WhaL nurslng lnLervenLlons could be used Lo enhance normal growLh and developmenL and ease Lhe sLress of
hosplLallzaLlon?
) Lducate mother on the nutr|t|on requ|rements for a mos o|d ch||d
2) Lncourage regu|ar use of the nebu||zer as ordered so that ch||d becomes use to |t and not an|ous about |t

1LACnING$LLAkNING$DISCnAkGL LANNING |dent|fy know|edge rec|p|ents

1each|ng 1op|c kead|ness to Learn Lva|uat|on of |earn|ng
1each parent s|gns of asthma
eacerbat|ons
Lmot|ona||y ready Not observed

1each parent to be aware of tr|ggers

Lmot|ona||y ready Not observed
nave parent keep a d|ary of tr|ggers Lmot|ona||y ready Not observed

1each proper use of nebu||zer
Lmot|ona||y ready erformed successfu||y


NUkSING NC1L
$$ 84 Lyeba|| Assessment A|ert act|ve s|tt|ng on moms |ap dr|nk|ng from a bott|e
8S mos fema|e adm|tted $$ for resp|ratory d|stress A|ert no apparent pa|n
Mucousy cough wheez|ng heard and auscu|ated b||atera||y kesp|rat|ons deep and even
subcosta| retract|ons No nasa| dra|nage Sk|n acyanot|c |oose turgor Abdomen soft and
nond|stended w|th bowe| sounds |n a|| 4 quads Moves a|| etrem|t|es equa| gr|p Cne wet
d|aper no odor no sk|n breakdown Ieet coo| and dry u|se o|meter taped to b|g toe (9
sat) Nebu||zer treament to|erated we|| Mother ho|d|ng ch||d |n cha|r Ca|| be|| |n reach
9SS S|eep|ng Spo2 probe off and rep|aced (9) kesp 28$m|n Ch||d on stomach |n cr|b S|de
ra||s up Mom |n cha|r
t up w|th mom |n game room
S S|tt|ng |n cr|b cry|ng 2 oz of Isom|| f|n|shed Cne wet d|aper changed 8aby be|ng
comforted by mom Wheez|ng auscu|ated b||atera||y Ca|| be|| w$|n moms reach
3 S|eep|ng on stomach Mom |n cha|r S|de ra||s up